Washington Update

A February 4 report by the Congressional Budget Office (CBO) on the impact of the Affordable Care Act (ACA) on the U.S. labor market set off a firestorm on Capitol Hill when it estimated that by 2024 some 2.5 million Americans who would have previously counted on a job for their health insurance will no longer decide to work or will shorten their hours.

January marked the fourth time in three years that Congress faced a potential debt-limit crisis, but this time brinksmanship was avoided. By mid-February, a bipartisan effort extended the well beyond the upcoming November elections—and the Tea Party received a strong rebuke.

The Obama Administration last month announced it would further delay the requirement that certain businesses provide health insurance to their employees, in some cases postponing the obligation until 2016, a full two years after the date originally set by the law.
The Affordable Care Act’s (ACA) so-called “employer mandate,” which applies to businesses with 50 or more employees, had originally been set to take effect in January, 2014, but was postponed until 2015 following pressure from the business community. In a February 10 announcement, the U.S. Treasury Department said it would again relax the requirements. Businesses with between 50 and 99 employees will now have until 2016 to provide health insurance to their employees.
In addition, businesses with more than 100 employees will now be allowed to comply over a two-year period. Most businesses with more than 100 employees already offer health insurance, the Treasury Department noted. But under the new rules, those that do not already provide health insurance will be required to offer it to just 70% of their employees by 2015 and 95% in 2016 and beyond. While only 2% of employers have more than 100 workers, these companies account for 66% of the private sector work force. The vast majority of businesses in the United States employ fewer than 50 people, and under the ACA they have never been subject to an employer mandate, something the Treasury Department stressed when making its announcement.
“While about 96% of employers are not subject to the employer responsibility provision, for those employers that are, we will continue to make the compliance process simpler and easier to navigate,” said Assistant Secretary for Tax Policy Mark J. Mazur.
Republicans on Capitol Hill pilloried the news of the postponement of the employer mandate, accusing the Obama Administration of changing the law unilaterally. Administration officials countered that they have wide latitude to grant what is known as “transition relief” in implementing the law.
The announcement of the delay in the employer mandate has added to the pressure on the Administration to relax the health insurance obligations for individuals as well, or at least postpone the enforcement of a tax penalty for people who forego coverage. Health policy analysts, however, note that the employer and individual mandates have different functions, and that the individual mandate is crucial for the solvency of the ACA. Unless enough healthy individuals sign up, insurance companies will not be able to afford the law’s more expensive changes: a ban on denying insurance because of pre-existing conditions and a ban on dropping people from a policy when they get sick.

On February 26, the Senate began floor debate on the Comprehensive Veterans Health and Benefits and Military Pay Restoration Act of 2014 (S.1982), which includes a number of provisions impacting academic dentistry.
Namely, Title III of Subtitle E (Dental Care Eligibility Expansion and Enhancement) in the bill provides:
The Secretary of Veterans Affairs may furnish restorative “dental services and treatment, and dental appliances” to veterans
Authorizes a three-year pilot program expanding dental care to all enrolled veterans at 16 sites nationwide.
The Secretary is directed to carry out a dental health educational program informing veterans on options for accessing dental care, including obtaining low or no-cost dental care through dental schools or Federally Qualified Heath Clinics (FQHC).
The proposed legislation authorizes $305 million in FY15, to be available for 5 years, to carry out these provisions.
Additionally, Title II of the bill deals with Education Matters:
It requires that, beginning on July 1, 2015, public institutions of higher education must charge veterans in-state tuition and fees regardless of the veteran’s state of residence.
In addition, it extends and expands the work-study program through June 30, 2015.
The ADEA Advocacy and Governmental Relations team will continue to monitor progress on this proposed legislation and its impact on academic dentistry.

Three Democratic Senators have introduced a bill they say will spur colleges to “innovate to reduce costs.” The College Affordability and Innovation Act of 2014 was introduced on January 29 by Chris Murphy (D-CT), Brian Schatz (D-HI) and Patty Murray (D-WA).
The legislation would do four specific things, according to a press release from Murphy’s office:
Create a new evidence-based competitive pilot program to encourage innovative ideas that may reduce the cost of a college education.
Rigorously evaluate these innovations.
Create a new commission to set out minimum accountability standards for any institution that receives federal funding.
Provide funding awards to institutions that perform best on these measures.
“[T]he message is clear,” Murphy said in a statement. “We need college administrators to wake up every day thinking about how they’re going to bring down the cost of college for students.”
College costs are at their highest levels ever and continue to rise. The press release noted that there are few incentives for colleges to test ideas that may lead to lower college costs. The bill’s evidence-based pilot program would both authorize and fund pilot projects that encourage institutions to design plans that offer high-quality education, lower costs and shorter time spans in which to earn a degree. The commission set up under the legislation would focus on standards evaluating access for low- and middle-income students, affordability and value.

Over the last decade, numerous studies have affirmed that individuals with neurodevelopmental and intellectual disabilities (ND/ID) such as autism, Down syndrome and cerebral palsy do not receive adequate health and oral care.
The American Academy of Developmental Medicine and Dentistry (AADMD) is leading a movement to see that ND/ID populations receive the federal designation of Medically Underserved Population (MUP) in order to improve their access to both health and oral care.
The organization notes that many physicians and dentists do not receive exposure to this population during their training even though ND/ID individuals comprise 7% of the U.S. population. In contrast, only one-tenth as many U.S. residents are living with HIV, yet 80% of medical students receive clinical exposure to that population. This gap in the educational arena translates into significant oral care disparities received by people with ND/ID and those received by the overall population.
A federal MUP designation could begin to remedy these problems by permitting special Medicaid reimbursement rates, educational loan reimbursement programs, research opportunities, and other incentives that would attract oral care providers to increase work with ND/ID patients.
The Health Resources Services Administration (HRSA) uses a formula, titled the Index of Medical Underservice, to determine whether a population should be accorded MUP status. With an estimated score of 54.1, under this formula ND/ID individuals should qualify for the underserviced designation afforded to all those with a score of less than 62.

Now that Congress has passed the appropriations bill for FY14, the next immediate gauntlet is the upcoming debt ceiling debate—the posturing has begun. Senate Budget Committee Chair Patty Murray (D-WA) released a letter warning that Democrats would not give into demands in exchange for raising the debt limit next month.

Sens. Richard Burr (R-NC), Tom Coburn (R-OK) and Orrin Hatch (R-UT) have unveiled the Patient Choice, Affordability, Responsibility, and Empowerment (CARE) Act with the idea of repealing the Affordable Care Act and offering this plan in its place. Some highlights of the bill follow:
The proposal would repeal the ACA’s requirements on individuals and employers to purchase health care coverage. Also, it would eliminate the health insurance marketplaces set up under the ACA.
Lifetime limits would still be prohibited and the proposal would ensure the ability to keep dependent coverage up to the age of 26, although a state could opt out of enforcing dependent coverage on the insurers that it regulates.
Individuals could not be charged more for preexisting conditions unless they have a gap in coverage at which time they could be subject to medical underwriting where insurers could charge them more for coverage based on medical history.
Employers could fully deduct the cost of providing health insurance. However, some employees getting generous coverage would have to pay taxes on the value of some benefits.
The ACA’s ban on charging an older, sicker person more than three times what a younger, healthier person is charged is replaced with a 5:1 ratio, and states would be able to decide whether they want a different rating rule.
The proposal envisions adopting or incentivizing states to adopt a range of solutions to tackle the problem of so-called “junk lawsuits” and defensive medicine.
Given the fact that any proposal that seeks to repeal and/or radically modify provisions of the ACA face a certain veto by President Obama, the prospects for the proposal’s serious consideration and passage are not promising.

With increasing numbers of health care organizations adopting electronic health records (EHRs), the National Academies’ Institute of Medicine (IOM) has released a discussion paper proposing a model to calculate the financial implications, benefits and costs of implementing EHRs and related technologies.
Return on Information: A Standard Model for Assessing Institutional Return on Electronic Health Records notes that health care has been “a reluctant late adopter” of information technology, lagging behind other industries. Nevertheless, the paper asserts that enactment of the Affordable Care Act (ACA) has spurred greater innovation in delivery systems, making standards-based, interoperable IT systems increasingly necessary in the future.
According to the paper, the goal of the proposed model is “to provide a clear framework and propose a standard model for evaluating institutional investment in EHRs and related technologies to enable inter-organizational comparisons, help identify best-in-class implementation approaches, and prioritize process redesign endeavors.”
A standard assessment model would make possible for the first time the direct comparison of vendor technologies or products based on a standard set of cost/benefit assumptions.

Senate Judiciary Committee Chairman Patrick Leahy (D-VT) introduced the latest version of a bill aimed at enhancing personal information and privacy. The Personal Data Privacy and Security Act of 2014, was first introduced by Leahy in 2005. The bills states that business entities that comply with both the Health Insurance Portability and Accountability Act of 1996 and the Health Information Technology for Clinical Health (HITECH) Act, would be in compliance with the legislation’s standards. These business entities include vendors of personal health records and third-party service providers.
The bill requires companies that have databases with sensitive personal information to establish and implement data privacy and security programs. It would also establish a single national standard for data breach notification and require notice to consumers when their personal information has been compromised. The bill would make it an explicit felony to damage critical infrastructure systems or information, with violators subject to as much as 20 years of imprisonment.
An earlier version of the bill passed the Judiciary Committee in the 112th Congress, but never saw Senate floor action. The new legislation is cosponsored by Sens. Richard Blumenthal (D-CT), Al Franken (D-MN) and Charles Schumer (D-NY).